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High Value Cost Conscious Care: Is it Rationing or Rational Care? 1_11_13

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LDI Charles Leighton, MD Memorial Lecture

LDI Charles Leighton, MD Memorial Lecture


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  • 1. E EM Q AS IR A M R OM High Value Cost Conscious g IS S IO N F RM Care: Is it Rationing or EN PE T IT Rational C O?WR R i l Care?R PRI O UT H IT W E UT Qaseem, MD PhD MHA Amir Qaseem MD, PhD, MHA, FACP B T RI IS Director, Clinical Policy, American College of Physicians D O R Chair, Guidelines International Network RE S HA NOTDO
  • 2. E EM Q AS IR Conflicts of Interest A M R OM F N  Financial: SIO IS  Employee of the American CollegeMof Physicians ER P  No other financial conflicts TE N T RI W OR RI  Non-financial: UT P OH  Guidelines International Network IT W T E  Institute ofUMedicine B T RI  Centers for Disease Control and Prevention IS D OR RE S HA NOTDO
  • 3. E EM Q AS IR A M R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA NOTDO
  • 4. E EM AS Cost of Health Care in the US A M IR Q R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA T NO CMS, Office of the Actuary, National Health Statistics GroupDO
  • 5. E EM Q AS IR A M R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA NOT Reinhardt, NY Times, 12/24/2010.DO
  • 6. E EM AS Diagnostic Imaging Studies in 6 LargeMIR Q A Integrated Health Care System R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA NOT Smith-Bindman R et al. JAMA. 2012;307:2400-2409.DO
  • 7. E EM Q AS IR A M R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA NOTDO
  • 8. E EM Q AS IR A M R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA NOTDO
  • 9. E EM AS Overtreatment A M IR Q R OM F N IO  Unnecessary treatment IS S RM  End of life care PE T EN  Excessive use of antibiotics R IT W  Generic vs non-generics OR or higher-priced PRI T services vs l i lessHexpensive alternates OU i lt t IT W UTE R IB ST DI OR RE S HA NOTDO
  • 10. E EM AS End of Life: Where Do Patients AMIR Q Die? OM FR N O  Hospital: ~53% 53% SI IS E RM P  Nursing home: ~24% TEN R IT W  Home: ~24% OR PRI  Data f D t from UT t di other studies: th HO IT W T E  Survey y data: 60-80% of people want to die U p p B at home T RI IS D OR  ~22% 22% RE of people die in an ICU S HA NOT Gruneir A et al. Med Care Res Rev. 2007; 64:351DO
  • 11. E EM AS The Cost of Wasted Resources and A M IR Q Unnecessary Diagnostic Testing OM FR N O SI IS E RM  Current waste: an estimated N$750 billion loss P in 2009 (IOM 2012) T TE RI W  Inappropriate diagnostic O R testing (i.e. testing PRI that is overused or OU Tmisused) is estimated to H IT cost approximately $210 billion per year (10% W E UT of annual Ihealth care costs) B T R (PriceWaterhouse (www.pwc.com) D IS OR RE S HA NOTDO
  • 12. E EM AS Excess Costs Domain EstimatesAMIR Q (30% of Health Care Costs) N FR OM O Cost in Billions of $$$ Cost in Billions of $$$ SI IS E RM P Unnecessary Services  $75  TEN ($210 B) $210  R IT Inefficiently Delivered  $55  W OR Services ($130 B) PRI Excess Administrative  $105  $105 O UT Costs ($190 B) Costs ($190 B) H Excessive Pricing ($105 B) IT W U TE $130  $130 Missed Prevention  R IB Opportunities ($55 B) I ST$190  Fraud ($75 B) D OR RE S HA NOT The Healthcare Imperative 2010 IOMDO
  • 13. E EM AS According to the IOM report A M IR Q R OM F ON  If banking worked like health care, ATM transactions g , SI IS would take days. RM PE  T EN If home building were like health care, carpenters, electricians and plumbers would work f l ti i d l b ld R IT k from diffdifferent t W blueprints. OR PRI  If shopping were like health care, prices would not be T posted and could vary H OUwidely within the same store, IT W depending on who was paying. E UT  If airline t RIBl were lik h lth care, i di id l pilots i li travel like health individual il t T would beISD free to design their own preflight safety checks — or OR perform one at all. E not p AR SH NOTDO
  • 14. E EM AS Are We Willing (and Able) to AMIR Q Address the Problem? OM FR N O SI IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA NOTDO
  • 15. E EM AS It Is Our Ethical and ProfessionalIR AM Q Responsibility to Control Cost! OM FR N O SI From Medical Professionalism in the New Millennium: A IS RM PE Physician Charter (ABIM-F, ACP-F, EFIM) EN “While meeting the needs of individual patients, physicians T are required to provide health care R IT that is based on the W OR wise and cost-effective management of limited clinical resources.” P RI T OU “The physician’s professional responsibility for appropriate H IT allocation of resources requires scrupulous avoidance of W E p UT superfluous tests and p procedures. The provision of p R IB unnecessary services not only exposes one’s patients to ST DI avoidable harm and expense but also diminishes the OR resources available for others.”others. E AR SH T OAnn Intern Med. 2002; 136:243-246 NDO
  • 16. E EM AS Physician Controlled Costs A M IR Q R OM F N  Unnecessary testing SIO IS and treatment $210B RM PE  Inefficiently delivered y T EN R IT care $130B W OR RI  Missed prevention T P p opportunities $55B H OU IT W  Total = $395B E UT B T RI S DI OR RE S HA NOTDO
  • 17. E EM Q AS IR A M R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA NOTDO
  • 18. E EM AS Why is there an overused or A M IR Q misuse? R OM F N  Lack of  IO Clinical performance S IS guidance/guidelines measures RM PE T EN  Lack of knowledge  RIT Discomfort with W R diagnostic uncertainty Insecurity about IO  PR clinical skills li i l kill O UT  Discontinuity of care Di ti it f H IT W  Patient expectations E  Inadequate time with BUT RI patients  Fear of ST Imalpractice D O R E  Habits  PARPersonal gainl i S H T NODO
  • 19. E EM AS Financial Incentives Can Drive AMIR Q Behavior OM FR N Stress Testing Within 30 Days of Outpatient Visit After O SI Coronary R C Revascularization (%) l i i IS M P ER EN 30 T T 25 RI W OR RI 20 P 15 O UT Tech+Prof H Fee IT 10 W Prof Fee UTE Only 5 R IB No Billing ST 0 DI R ONo Symptoms CABG PCI Overall RE Symptoms S HA T NO BR et al. JAMA. 2011; 306:1993 ShahDO
  • 20. E EM AS Financial Incentives Can Drive AMIR Q Behavior OM FR N O  S SI A review of ownership of nuclear Imyocardial perfusion studies among MedicareRM patients: PE T EN  cardiologists cardiologists’ offices increased 215% between T RI 1998 and 2006, W O R RI  radiologists and other physicians increased 32% P T OU and 181% respectively H IT W UTE R IB ST DI OR RE S HA T NO DC et al. J Am Coll Radiol. 2009;6(6):437-441 LevinDO
  • 21. E EM AS Financial Incentives Can Drive AMIR Q Behavior OM FR N O  Self employed Self-employed urologists (who owned office- SI office IS based imaging equipment) were RM2 to 5 times PE g ITgT EN more likely to order imaging for a variety of y y R W urinary conditions compared with those OR urologists who wereP in g RI employment based p y T OU practice modelsH(salaried and not owning IT equipment)UTE W B T RI S DI OR RE S HA T NO Hollingsworth JM et al. J Urol. 2010;184(6):2480-2484DO
  • 22. E EM AS Physicians Lack Understanding About BenefitIR Q A M of S f Screening T i Tests OM FR N S IO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA OT Wegwarth O et al. Ann Intern Med 2012;156:340-349 NDO
  • 23. E EM AS Ovarian Cancer Screening: A M IR Q What are the Recommendations? OM FR N O  D SI Routine screening: “D” grade (USPSTF) IS E RM  High risk (based on family Ehx.): referral for N P genetic counseling and RITT BRCA testing W (USPSTF and ACOG) RI O R P T  +BRCA1 or +BRCA2: candidate f risk- BRCA1 BRCA2 H OU did t for i k IT reducing surgery, not screening (Soc. Gyn. E W UT Onc.) Onc ) RIB T D IS O R E AR SH OT Baldwin L-M, et al. Ann Intern Med. 2012; 156: 182. NDO
  • 24. E EM AS Ovarian Cancer Screening: A M IR Q What Do Physicians Think? N FR OM O  1/3 say transvaginal ultrasound or SI IS RM Ca-125 is an effectiveEscreening PE N T IT test t t W R OR  Study used case g y PRI vignettes T OU  65% offered ITH screening to medium-risk W woman UT E B T RI  29%Soffered screening I to low-risk woman D O R E AR SH OT Baldwin L-M, et al. Ann Intern Med. 2012; 156: 182. NDO
  • 25. E EM AS Defensive Medicine A M IR Q R OM F N IO  $45.6 $45 6 billion in 2008 for hospital and IS S RM 29: 1569-1577) physician spending (Mello et al, Health Affairs 2010; PE EN  Most common forms (Studdert et T JAMA 2005;293: 2609-2617) RI T al al, 2609 2617) W  Over-ordering of diagnostic tests O R PRI  Unnecessary referrals T H OU  Avoidance of WIT high-risk patients U TE R IB ST DI OR RE S HA NOTDO
  • 26. E EM AS Defensive Medicine A M IR Q R OM F N IO  “when doctors order tests procedures or when tests, procedures, IS S visits, or avoid certain high-risk patients or RM PE p procedures, p , primarily ( ITT y (but not EN solely) because y) R W of concern about malpractice liability --- US OR g PRI Congress Office ofT Technology Assessment gy H OU  Says nothing about the damages that patient IT W T E could incurUfrom excess or unnecessary y B screening T RI IS D OR RE S HA NOTDO
  • 27. E EM AS Do Physicians Agree That A M IR Q Healthcare is Overused? R OM F N IO Survey of primary care physiciansISS E RM  42% believe patients in theirPown practice T EN are receiving too much care (vs 6% who R IT (vs. W say “too little”) O R PRI  Perceived factors T leading to overuse OU H IT  Malpractice W E concerns: 76% UT  Cli i RIB f Clinical performance measures: 52% l S T DI  Inadequate time to spend with patients: 40% OR RE S HA NOT Sirovich B et al. Arch Intern Med. 2011; 171:1582-1585DO
  • 28. E EM Q AS IR A M R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA OT N Owens D; Qaseem A et al. Ann Intern Med. 2011; 154:174-180DO
  • 29. E EM AS Value = Benefits, Harms, Costs AMIR Q R OM F  Value = benefit / (cost + harm) SIO N IS  Cost ≠ Value RM PE EN  Cost includes cost of testTand downstream T RI costs, benefits and harms W O R PRI  High cost interventions may provide good T H OU value because they are highly beneficial W IT E Low cost T  Low-costUinterventions may have little or B T RI no value if they provide little benefit or D IS R increase downstream costs. R E O S HA OT NOwens D; Qaseem A et al. Ann Intern Med. 2011; 154:174-180DO
  • 30. E EM AS Benefit, Cost, and Value A M IR Q R OM High Benefit F Low Benefit N O SI IS M High Anti-retroviral ER Routine MRI for low P therapy for HIV N backTpain E Cost T RI W Value: high O RValue: low PRI O UT Low HIV screening H Annual pap smears IT Cost W UTE R IB T Value: high Value: low D IS OR RE S HA OT N Owens D; Qaseem A et al. Ann Intern Med. 2011; 154:174-180DO
  • 31. E EM AS Value Measurement: Quality MIR Q A Adjusted Life Years (QALYs)ROM F N IO  An important metric for measuring health S IS RM benefits by taking into accountEboth length P N and quality of life q y TE ITR W I OR PR  Allows for comparison of interventions UT HO IT between different specialities (compare W E UT cancer treatments with cardiovascular B T RI treatments) D IS OR RE S HA NOTDO
  • 32. E EM AS Four interventions, A, B, C, D A M IR Q R OM F A is better and cheaper ND IO than S IS E RM P TEN R IT B is better than A b i b h but W more expensive OR PRI O UT H IT W UTE C is better than B but IB more expensive T R S DI OR RE S HA OT N Owens D; Qaseem A et al. Ann Intern Med. 2011; 154:174-180DO
  • 33. E EM AS Cost-Effectiveness Threshold: MIR Cost- Q A How Much is Health Worth?ROM F N  Threshold depends on who is making the S IO IS decision and their willingness toPpay for better E RM health outcomes T EN R IT  National Health Service R in WUK $30,000-$50,000/ O QALY PRI T  No consensus in H USOU - citizens have been willing IT W to pay up to $109,000/QALY, most US decision E BUT k T RI id makers consider interventions that cost l i i h less than h S DI $50,000-$60,000/QALY high value OR RE S HA T NODO
  • 34. E EM AS QALY Examples A M IR Q OM Intervention Cost Effectiveness N FR Ratio O SI Prevention M P ti Measures IS RM High intensity smoking prevention $190/QALY E P N T TE Screening 60 y o for Diabetes $ RI $25,738/QALY W O R RI Treatments for existing conditions P T ART for HIV OU $29,000/QALY I TH W Implantation of defibrillators $52,000/QALY U TE oIB Surgery in 70 y R male with Increased cost and worsens T prostate ca DIS health OR RE S HA T NO Cohen JT et al. N Engl J Med 2008;358:661-663DO
  • 35. E EM AS How Can We Reduce A M IR Q Inappropriate Care? R OM F N IO  Develop guidance for physicians Iabout SS appropriate use of care, focusing RM initially on PE diagnostic testing g g T EN IT R  Assemble and integrateRevidence-based and W O RI consensus-based recommendations P  Ed Educate t UT t target audiences about areas of t HO di b t f IT overuse andEmisuse of care: W  Trainees IB UT (students, residents, and fellows) (students residents T R IS www.highvaluecarecurriculum.org D R  Practicing clinicians E O g R APatients SH NOTDO
  • 36. E EM AS Key Features of Bringing Cost Consciousness IR Q A M into the T i i E i i h Training Environment OM FR N  Approach: focus on appropriate careS S IO rather than I saving money RM PE  Knowledge: understanding of EN T what helps h ti fl RIT patients vs. what is superfluous or even harms ti t W h patients OR PRI  Philosophy: recognition that more ≠ better T H OU  Faculty development: trainees mimic faculty IT behavior TE W U  R IB Assessment: of trainee knowledge and behavior ST  DI Regulation: cost consciousness in residency OR competency requirements RE S HA NOTDO
  • 37. E EM AS Towards High-Value Cost-Conscious Care High- Cost- IR Q AM M Ocare  Ask appropriate questions at the point of FR N  Did the patient have this test previously? SIO IS  RM Will the result of this test change the care of the patient? PE T EN  R IT What are the probability and potential adverse W consequences of a false positive result? OR  Is the patient in potentialI danger in the short term if I do PR not perform thi t Ot? t f UT this test? H  Am I ordering W IT test primarily because the patient the wants it orUTEreassure the patient? to B  Observe T RIand provide feedback to trainees on D IS their O R provision of high value care- let them E AR H know if they are wasting resources! S NOTDO
  • 38. E EM Q AS IR A M R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB IdentifiesIST clinical situations in which a screening or 37 D diagnostic test does not reflect high value care. R O RE S HA T OQaseem et al. Ann Intern Med. 2012; 156:147-149. NDO
  • 39. E EM AS Overused Dx Tests A M IR Q R OM F  Screening for colorectal cancer in adults ON SI older than 75 y or in adults withRa life IS M PE expectancy of less than 10 yN T TE  Performing imaging studies RI in patients with W O R nonspecific low backRIpain P UT  Ordering routine O H preoperative laboratory IT W tests, including complete blood count, liver E UT chemistryIB TR tests, and metabolic profiles, in f S DI otherwise healthy patients undergoing OR l RE ti elective surgery HA S T NODO
  • 40. E EM AS Overused Dx Tests A M IR Q R OM F N Performing brain imaging studies (CT Ior MRI) to IO  SS evaluate simple syncope in patients RM normal E with P findings on neurologic examination N T TE  Obtaining CT scans in a patient RI with pneumonia that W O R is confirmed by chest radiography in the absence of RI P complicating clinical U T radiographic features or H O  Performing imaging IT studies, rather than a high- W E DBUT sensitivity D-dimer measurement, as the initial dimer I diagnosticRtest in patients with low pretest probability IS T D of venous thromboembolism O R RE S HA NOTDO
  • 41. E EM Q AS IR A M R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA T OChou R; Qaseem A; et al Ann Intern Med. 2011; 154:181-189 NDO
  • 42. E EM AS Example of Healthcare Waste A M IR Q R OM F N IO  Patient with uncomplicated back pain without IS S any red flags RM PE EN  Total cost of workup and RITT treatment done in W this case (plain films, IMRI, physical therapy): O R PR $10,821.93 T H OU IT  Total cost of workup and treatment that would W E UT be recommended by ACP guideline : $908 IB R T DIS OR RE S HA NOTDO
  • 43. E EM Q AS IR A M R OM F N SIO IS E RM P EN T  I addition t measure underuse of care, In dditi to RdIT f W need to develop evidence-based OR PRI T performance measures to assess use of low low- H OU value interventions IT W E UT  ServicesIBwhere harm exceeds the zero to R ST negligible benefit DI OR RE S HA T NO Baker D; Qaseem A et al. Ann Intern Med. 2013; 158DO
  • 44. E EM AS Patient Education A M IR Q R OM  Shared-decision making N F O SI  Involve patients and their familiesS M I P ER  According to a recent IOM report: N E T  69 percent patients want th t ti t t WR ITi provider t t ll th their id to tell them OR the risks of the treatment options so they will know PRI how each might affect them T OU  53 percent wantHto know about each option’s cost IT W to themselves E and their family. BUT  47 percent T RI patients want their health care provider IS to OR D discuss the option of not pursuing a test or tE t Atreatment R t SH T OIOM 2012. Communicating with patients on health care evidence. NDO
  • 45. E EM AS Patient Education A M IR Q R OM  Annals of Internal Medicine Summaries for N F O Patients SI IS RM http://www.acponline.org/clinical_informati PE T EN on/guidelines/ R IT W  ACP Foundation’s Health TiPS OR PRI T  Collaborations with consumer OU H IT organizations (e.g., Consumer Reports) W E that include BUT videos and educational T RI IS materials D OR RE S HA NOTDO
  • 46. E EM Q AS IR A M R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB S T DI OR RE S HA N OT http://www.consumerreports.org/cro/2012/04/best-health-tests-and-treatments- often-cost-less/index.htmDO
  • 47. E EM Q AS IR A M R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA NOTDO
  • 48. E EM AS Options?? A M IR Q R OM F N IO  Patients share the financial burden burden… IS S RM PE  Financial incentives for physicians and T EN change in the reimbursement system R IT system…. W  Team-based care….RIO R P O UT H IT W UTE R IB ST DI OR RE S HA NOTDO
  • 49. E EM AS Hurdles?? A M IR Q R OM F N IO  Litigation system IS S RM  Transparency (costs, charges,Eetc)N P T TE  Heterogeneity in circumstances RI W R  Anecdotal evidence RIO P O UT H IT W UTE R IB ST DI OR RE S HA NOTDO
  • 50. E EM AS Recommendations for High- High- IR Q A M V l C -C Value Cost Conscious C Cost- i Care FROM N S IO  Understand the benefits, harms and relative costs of the benefits harms, IS M interventions that you are considering ER P N Decrease or eliminate the use of interventions that provide  T TE no benefits and/or may be harmful RI W  Choose interventions and care O R settings that maximize P RI benefits, minimize harms, and reduce costs (using , T, ( g OU comparative effectiveness and cost effectiveness data) H IT  W Customize a care plan with the patient that incorporates E their valuesIBUT addresses their concerns and R  ST Identify Isystem level opportunities to improve outcomes, D R minimize harms, and reduce healthcare waste O RE S HA NOTDO
  • 51. E EM Q AS  Issue of the decade starting in 2010: M IR A decreasing the cost of care f OM FR  The rise in health care costs is notSION IS sustainable RM PE  Cost containment measures N happenTE will T RI  Costs can not be controlled unless R W IO Rsubstantially reduced inappropriate care Tis P OU  Why should youHcare about cost? IT W  Physicians y U TE responsible for 87% of spending p p g B RI T  Physicians can be part of the solution or D IS R viewed as part of the problem R E O S HA NOTDO
  • 52. E EM AS Conserving resources through AMIR Q M providing high value care does N FR Onot IO mean rationing! RM IS S PE  Rationing: decisions are made about the EN T allocation of scarce medical ll ti f diR IT l resources and d W OR who receives them, leading to underuse of PRI potentially appropriate care T H OU IT  Rational or high value care: assuring that E W UT care is clinically effective thus avoiding RI B effective, T overuse D IS or misuse of care that is O R inappropriate AR E SH OT T; Qaseem A et al. Arch Intern Med. 2012 N WiltDO
  • 53. E EM Q AS IR A M R OM F N SIO IS E RM P TEN R IT W OR PRI O UT H IT W UTE R IB ST DI OR RE S HA NOTDO